肺隐球菌病（PC，pulmonary cryptococcosis ） ---从一个病例谈起
复旦大学附属华山医院北院呼吸科 张有志
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病史介绍
患者，女性，47岁
主述：因“反复咳嗽伴胸痛1月”入院（B院） 现病史：患者于2010.9.5无明显诱因出现咳嗽，少量白痰，伴右
侧胸痛，阵发性钝痛，深吸气时明显，无放射痛，无发热，无 呕吐、头痛，某A院行胸部CT示“右下肺炎”，予以莫西沙星 静滴8天患者咳嗽、胸痛有所缓解，继续口服莫西沙星6天， 2010.9.27复查CT无吸收。于2010.10.12就诊B院。
中国临床医学，2013,20（3）：351-354
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Epidemiology III
Retrospective investigation of 151 pulmonary cryptococcosis non-HIV cases between 1977 and 2012
• 44.4% patients had no UDs. • The common UDs were diabetes (32.1%) hematologic disease (22.6%) collagen disease (22.6%)
Totally 474 cases of pulmonary mycosis from 16 centers in10 cities.
• pulmonary aspergillosis(1 80 cases，37．9％) • pulmonary candidiasis(162 cases，34．2％) • pulmonary cryptococcosis(74 cases，15．6％) • pneumocystis cafinii pneumonia(23 cases，4.8％) • pulmonary mucormycosis(10 cases，2．1％)
Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases .J Infect Chemother. 2014 Oct 29
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Epidemiology IV
• 219 patients with proven cryptococcosis at 20 hospitals in Taiwan, 1997-2010
condition (54/219, 24.6%). • Among HIV-negative patients, liver diseases (HBV
carrier or cirrhosis) were common (30.2%)
Taiwan Infectious Diseases Study Network for Cryptococcosis. PLoS One. 2013 Apr 17;8(4):e61921.
既往：体健。否认性病冶游史。家中曾养宠物（鸽子、狗）。 查体：T：37.9 ℃，浅表淋巴结不大，右下肺可及湿啰音。
辅助检查：
血常规、肝肾功能、D-二聚体正常；ESR：65mm/h，CRP： 48mg/L；血气分析正常；HIV（-） PPD试验阴性；LA试验、G试验阴性（送至C院检测）
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2010.9.6 A院CT 2010.9明显异常； 右下肺灌洗和刷检：未见恶性细胞、TB阴性。
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2010.10.12 B院 CT引导下经皮肺穿刺
• 病理结果确诊： 肺隐球菌病
上皮样肉芽肿性病变； 成堆隐球菌
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几点疑问
• 真菌病一般都是免疫功能低下的患者 • 隐球菌如何侵袭到肺的 • LA试验阴性 • 肺隐球菌病CT表现和肺炎一样
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关于隐球菌Ｃｒｙｐｔｏｃｏｃｃｕｓ
• 带厚荚膜的酵母菌（乳胶凝集试验） • 腐生菌：土壤、鸽粪、霉烂蔬菜、水果等 • 感染部位：中枢神经系统、皮肤、肺 • 感染途径：吸入呼吸道经血行播散到其它部位 • 分型：17个种、18个变种 （新生隐球菌及变种具有致病性）
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Epidemiology I
A multicentre retrospective study of pulmonary mycosis clinically proven from 1998 to 2007
Shanghai Pulmonary Hospital .Eur Respir J. 2012 Nov;40(5):1191-200.
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Epidemiology V
• Clinical analysis of 76 patients pathologically diagnosed with pulmonary cryptococcosis.
• Of 76 patients (54 males and 22 females), 41 (53.95%) were immunocompetent and 35 out of the 41 were asymptomatic.
210 isolates were C. neoformans (95.9%); 9 isolates were C. gattii (4.1%). • 15.4% did not have any underlying condition. • HIV infection was the most common underlying
中华结核和呼吸杂志，2011,34(2)
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Epidemiology II
Meta-Analysis of Clinical Manifestations of Pulmonary Cryptococcosis in China Mainland • 69.7 % patients had no underlying diseases． • The common underlying diseases were acquired immune deficiency syndrome( AIDS) diabetes malignant tumor